Your Daily Meds - 13 December, 2022
Good morning and welcome to your Tuesday dose of Your Daily Meds.
Bonus Review: How is coronary blood supply to the left and right ventricles affected during the cardiac cycle?
Answer: Supply to the left ventricle occurs almost entirely during diastole. For example, sub endocardial flow to the left ventricle ceases during systole. The pressure is just to high in the LV myocardium to for coronary flow to continue.
The right ventricle is a lower pressure house. Coronary flow is continuous during systole and diastole in the right ventricle. (Just with a reduction, not cessation, of flow during systole - unlike the high pressure left ventricle.)
Lets get Ethical:
You receive handover from the outgoing ED Consultant about a patient of concern. A 14-year-old male presented earlier in the afternoon with severe penile pain and was found to have a paraphimosis requiring intravenous analgesia and topical sugar application in order to retract the foreskin over a notably oedematous glans.
The boy’s foreskin was notably inflamed and friable afterwards.
At bedside handover, the ED Consultant discusses the incredibly bad outcomes if this were to happen again (emphasising penis-threatening erections!!), necessitating emergency circumcision (which cannot be done at your hospital and would necessitate emergency transfer to a centre with Urological services) to prevent an episode of ‘dead penis’.
The boy is asked to remain in the ED for a few hours for observation.
An hour after that ED Consultant leaves, and now after daylight hours, you are called to the bedside. The boy would like to discharge against advice, to go home and play video games.
What will you do? Can you keep this child in the Emergency Department against his will? Does he have capacity to make the decision to leave against advice?
A quick Case:
A young male has suffered a traumatic injury to a peripheral nerve in his upper limb. Findings: Unable to extend at the wrist and fingers; Sensory loss of the dorsal surface of the lateral three and a half digits.
Which of the following nerves is most likely to have been injured?
On Foreskins and Competence: (this will be the best sub-heading I write in my life)
There are times when children can make decisions for themselves that are not in keeping with the wishes of their parents (who were not available in the case of ‘foreskin boy’) or medical providers, and those decisions must be respected under Australian Law and the principles of Medical Ethics.
The age at which a person becomes an ‘adult’ in Australia is universally fixed by legislation at 18. People under that age are presumed to be ‘incompetent’ (to make healthcare decisions) until they hit 18 when they magically become ‘competent’.
This is silly. Because, naturally, the parental power to consent to medical treatment on behalf of a child diminishes gradually as the child’s capacities and maturity grow and that this rate of development depends on the individual child - zero capacity as a newborn; full capacity at 18. (for the most part - again there is lots of ethical stickiness in the corner cases, but I digress)
So if, for example, a Mrs Gillick did not want her teenage daughters receiving contraception advice without her knowledge, she can suck it. So long as the daughter has achieved a sufficient understanding and intelligence to enable her to understand fully what is proposed.
This Gillick case was real and was taken to the English House of Lords in 1986. The judges politely told the mother to suck it and gave us the term ‘Gillick competence’ to describe the standard that children must meet to provide consent. We follow the British, so we literally use the same rule.
So in this case, you would need to test the capacity of ‘foreskin boy’ to determine if he meets Gillick competency. This would involve a discussion about the risks of leaving and establishing that the boy can understand, retain and use that information to make an un-coerced decision.
There, that’s the answer.
Ethics is interesting and the niche cases are particularly so. For example, what would happen if a competent child (they had passed the test for Gillick competency) refused life sustaining treatment. I dunno, like a 15-year-old Jehova’s witness boy refusing a blood transfusion for cancer treatment……
Well, that’s a story for another time.
Ethics is interesting…
In this case, the classic sign of ‘wrist drop’ along with the associated sensory changes is most suggestive of radial nerve injury.
Comes from: supplied by roots of C5-T1; is a continuation of the posterior cord of the brachial plexus.
Sensory: much of the posterior skin of the forearm, dorsal surface of lateral palm and the lateral three and a half fingers.
Motor: innervates the triceps brachii and many of the muscles in the extensor compartment of the forearm.
Common places of injury: axilla (with glenohumeral dislocation or poorly used crutches); radial groove of the humerus (fracture of the humeral shaft); forearm (with lacerations or fractures/dislocations of the radius).
Bonus: Is capillary blood flow intermittent or continuous?
Answer in tomorrow’s dose.
News: I made a little Ward Call Course for you all. It maps out an Evening Ward Call shift and covers a bunch of common tasks that you may need to do, like:
Difficult patients - Discharge Against Medical Advice, Ryan’s Rule
End of Life etc
You can find the course page here:
It’s free and always will be. Let me know what you think.
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As always, please contact me with any questions, concerns, tips or suggestions. Have a great day!